de Havilland Canada DHC-2 MK 1, VH-BVA

The pilot of the de Havilland Beaver floatplane registered VH-BVA was conducting a charter positioning flight from Hamilton Island Marina to Chance Bay, Whitsunday Island. He had landed at Chance Bay seven times in the previous two days. Weather conditions in the area were good. At 1700 Eastern Standard Time the Hamilton Island automatic weather station recorded a 7 - 10 knot wind from the northwest. Witnesses in Chance Bay said that the surface wind in the bay was 2 - 5 knots. The water surface in Chance Bay was smooth, but not glassy.

The pilot said that he commenced a straight-in approach to Chance Bay but elected to go around due to the increased number of vessels moored in the bay since the previous flight. He flew a left circuit at 500 feet and assessed that the area for landing was adequate. He said that on final approach, the flight path was higher than he would have preferred. His intention was to touchdown before passing abeam the vessels. He recalled that the floatplane speed shortly before touchdown was about 80 knots, rather than the target speed of 70 knots. He said that his response at this time was consistent with flying a landplane in that he reduced the back pressure on the control column and allowed the floatplane to contact the water at a lower nose attitude, and at a higher speed, than was ideal. Upon touchdown, the floatplane yawed sharply left 50 - 60 degrees and headed directly towards the anchored ketch 'Seark', about 300 m away. The pilot said that the water rudders (at the rear of each float) were retracted, so all the yaw control he had available was via the conventional aerodynamic rudder. As the aircraft yawed, it felt as though the rudder was stuck at full left deflection, but he thought that this was due to hydrodynamic drag. When the floatplane was an estimated 100 m from the 'Seark', it swung right so that it was heading slightly to the east side of the 'Seark'. However, the outer portion of the floatplane's left wing subsequently collided with the rear mast of the 'Seark'.

A video recording of the event showed that the floatplane touched down with a lower nose attitude than was ideal. It also showed that the left float touched the water first. The sharp left yaw followed immediately. The aircraft became airborne momentarily, shortly after initial touchdown.

The left wing of the floatplane and the rear mast of the ketch were substantially damaged. There were no injuries to the pilot or the three occupants of the ketch.

The video recording supported the pilot's description of the event. Together they indicated that the landing technique employed by the pilot was likely to have established the centre of rotation forward of the centre of gravity with respect to the left float when it contacted the water. Under such conditions, the floatplane would have been directionally unstable and a sharp left yaw was likely. The pilot may have applied up elevator after touchdown but did not regain sufficient directional control to prevent the aircraft from colliding with the yacht.

The evidence indicated that company floatplane pilots were selecting a landing direction that provided about 50 m lateral separation from moored vessels. This separation is greater than the minimum required under marine regulations but was insufficient to prevent a collision on this occasion. The minimum separation required under marine regulations was clearly inadequate to provide a safe margin, particularly given the benign environmental conditions that existed at the time of the accident. Aviation regulations and supporting advisory material do not provide any guidance for de Havilland Beaver aircraft operators and pilots regarding appropriate lateral separation from moored vessels or other obstacles during take-off and landing operations.

The technique employed by the pilot to achieve the intended touchdown was not appropriate for floatplane operations. Its use indicated shortcomings in the floatplane endorsement training received by the pilot and reflected the pilot's low level of experience in floatplane operations. The number of water landings under supervision completed by the pilot was considerably less than that required by other floatplane operators.

It was inappropriate for the chief pilot, given his limited floatplane experience, to be responsible for company floatplane operations, with no formalised support from appropriately experienced floatplane pilots.

Analysis of the pilot's flight and duty time records suggested that fatigue did not play a role in the development of the accident.

The contribution of the misaligned floats to the development of the accident could not be determined. The lack of any maintenance release record concerning the handling characteristics of the aircraft suggests that pilots who flew the aircraft may not have considered that any aspect of the aircraft's handling characteristics warranted rectification.

History of the flight

The pilot of the de Havilland Beaver floatplane registered VH-BVA was conducting a charter positioning flight from Hamilton Island Marina to Chance Bay, Whitsunday Island. He had landed at Chance Bay seven times in the previous two days. Weather conditions in the area were good. At 1700 Eastern Standard Time the Hamilton Island automatic weather station recorded a 7 - 10 knot wind from the northwest. Witnesses in Chance Bay said that the surface wind in the bay was 2 - 5 knots. The water surface in Chance Bay was smooth, but not glassy.

The pilot said that he commenced a straight-in approach to Chance Bay but elected to go around due to the increased number of vessels moored in the bay since the previous flight. He flew a left circuit at 500 feet and assessed that the area for landing was adequate. He said that on final approach, the flight path was higher than he would have preferred. His intention was to touchdown before passing abeam the vessels. He recalled that the floatplane speed shortly before touchdown was about 80 knots, rather than the target speed of 70 knots. He said that his response at this time was consistent with flying a landplane in that he reduced the back pressure on the control column and allowed the floatplane to contact the water at a lower nose attitude, and at a higher speed, than was ideal. Upon touchdown, the floatplane yawed sharply left 50 - 60 degrees and headed directly towards the anchored ketch 'Seark', about 300 m away. The pilot said that the water rudders (at the rear of each float) were retracted, so all the yaw control he had available was via the conventional aerodynamic rudder. As the aircraft yawed, it felt as though the rudder was stuck at full left deflection, but he thought that this was due to hydrodynamic drag. When the floatplane was an estimated 100 m from the 'Seark', it swung right so that it was heading slightly to the east side of the 'Seark'. However, the outer portion of the floatplane's left wing subsequently collided with the rear mast of the 'Seark'.

A video recording of the event showed that the floatplane touched down with a lower nose attitude than was ideal. It also showed that the left float touched the water first. The sharp left yaw followed immediately. The aircraft became airborne momentarily, shortly after initial touchdown.

The left wing of the floatplane and the rear mast of the ketch were substantially damaged. There were no injuries to the pilot or the three occupants of the ketch.

Landing area

Witnesses estimated that landing floatplanes (including this accident floatplane prior to touchdown), were passing about 50 m abeam the anchored yachts.

Civil Aviation Advisory Publication (CAAP) 92-1(1) 'Guidelines for aeroplane landing areas' stated that "a minimum width water channel of 60 m ... is recommended" for single-engine and centreline thrust floatplanes not exceeding 2,000 kg maximum take-off weight (MTOW). There were no diagrams or other guidance material provided for floatplanes greater than 2,000 kg MTOW or for multi-engine floatplanes. The MTOW for the accident floatplane was 2,313 kg. The Transport Operations (Marine Safety) Regulations (Queensland) 1995 s95 (1)(a)(ii) required that vessels operating at speeds greater than 6 knots must not approach within 30 m of a moored vessel.

Float alignment

Another company floatplane pilot reported that the aircraft required greater than normal right rudder input to maintain a constant heading during flight. During an inspection after the accident, maintenance personnel established that the floats were aligned slightly left of the aircraft's longitudinal axis. The aircraft manufacturer commented that the reported flying characteristics were consistent with the float alignment. The aircraft had been flown 23.8 hours since the last maintenance inspection, including about 10 hours by the accident pilot. No record had been made in the aircraft maintenance release regarding the 'in-flight' or 'on-water' handling characteristics.

Floatplane stability on the water

The ideal landing attitude for a floatplane is nose high, so that the rear portion of the float contacts the water first. If a floatplane lands at too high a speed (lower nose attitude than ideal), the point of contact of the floats with the water (that is, the centre of rotation of the floatplane) is at a position on the floats that is forward of the aircraft's centre of gravity and the aircraft's directional stability is reduced. If the loss of directional stability is not too severe, the pilot may be able to regain control if nose-up elevator is applied very rapidly to move the centre of rotation aft, behind the centre of gravity.

Pilot information

The pilot was the chief pilot of the company. Of his 11,256 hrs total flight time, 34 hrs were in floatplane operations, and included 79 water landings.

The pilot commenced floatplane endorsement training in October 2001. The endorsement was issued on 12 February 2002, after four sessions of training in Cessna 206 floatplanes involving 4.1 hrs and 16 water landings. Between 15 March and 25 July 2002, the pilot conducted four sessions in command under supervision in de Havilland Beaver floatplanes, involving 7.3 hrs and 23 water landings. On 25 July 2002 the company floatplane training pilot authorised the pilot to conduct solo commercial operations to specific destinations but noted that he was to be closely monitored in marginal conditions until he was more experienced.

The accident flight was the last flight of the day for the pilot. He had completed five flights with a total of 3 hrs flight time and 10 hrs duty time before the accident. The day before the accident the pilot had completed 10.2 hrs duty, including 4.8 hrs flight time during eight flights. The day prior to that was a rostered day off. He reported that neither fatigue nor any other personal issues had impaired his ability to safely operate an aircraft on the day of the accident.

The pilot's work/rest history for the 14 days prior to the accident was examined using a computerised fatigue algorithm developed by the Centre for Sleep Research, University of South Australia. The results indicated that the pilot was not experiencing significant levels of fatigue in the week leading up to, and on the day of, the accident.

Organisational information

At the time of the accident, the company employed an experienced floatplane pilot who conducted all the accident pilot's floatplane endorsement and in command under supervision training. The authority, duties and responsibilities of this floatplane pilot were not established or formalised in either the Civil Aviation Safety Authority (CASA) issued instruments of approval for key company personnel, or in the company operations manual.

The company operations manual stated that pilots with less than 250 water landings were subject to the direct supervision of the chief pilot who was to take into account the wind strength, wind direction, turbulence, tide and sea state at the origin and destination of the flight before approving a flight. There was no provision in the operations manual for when the chief pilot did not have the minimum 250 water landings experience. (Other companies required up to 300 water landings in command under supervision and 50 hours total floatplane flight time before solo commercial flight operations were permitted.)

For VFR charter in single-engine aircraft, CASA required that a pilot hold a commercial licence and the applicable aircraft special design feature endorsement, for example float alighting gear. CASA did not specify additional minimum experience requirements on the aircraft type or the special design feature.

Chief pilot appointment

Civil Aviation Order 82.0 required that a chief pilot hold licences, endorsements and ratings that permit command of all company operations. CASA had approved the pilot's appointment as chief pilot for the operator on 19 April 2002. At that time, he had obtained a float alighting gear endorsement but had not been authorised by the company to conduct solo commercial floatplane operations.

Local Safety Action

Civil Aviation Safety Authority

On 1 December 2002, the Civil Aviation Safety Authority revised the chief pilot's instrument of approval, specifying a condition that required the employment of a full-time senior float pilot.

On 20 August 2003, CASA provided the following information with respect to guidelines for aeroplane landing areas: 'As there are several levels of jurisdiction over waterways, CASA has raised with State Governments, through the Commonwealth/States/Territories Aviation Working Group, the question of whether there should be a joint review of the existing arrangements.'

Operator

In a letter to the Australian Transport Safety Bureau dated 11 June 2003, the operator advised that it had amended the company operations manual to reflect the appointment of a senior float pilot and revised the floatplane operations section of the operations manual. The operations manual stipulated that the senior float pilot was responsible to the chief pilot for the overall conduct of company floatplane operations.

The operator advised that it had appointed a new chief pilot.

An experienced floatplane pilot provided a report to the operator regarding company floatplane operations. Recommendations from that report included:

additional theoretical and practical training and checking for company floatplane pilots;
development of a company-specific pilot training guide; and,
review and amendment as required of the company floatplane authorised landing area guide.

The floatplane pilot who wrote the report for the company has been retained to implement the changes recommended.

The company also advised that it intended to upgrade the facilities at its floatplane base to allow pilots improved access to weather, flight planning and operational reference information.

The company advised that it planned to implement a fatigue management system for pilots, including modifying the daily work schedule to allow adequate rest periods.